The comprehensive assessment of defense style: measuring defense mechanisms in children and adolescents

Childhood chronic condition and subsequent self-reported internalizing and externalizing problems in adolescence: a birth cohort study

Chronic conditions are common in childhood. We investigated the associations of childhood chronic conditions reported by parents with subsequent self-reported internalizing and externalizing problems in adolescence. A sample of 6290 children (3142 boys and 3148 girls) with data on chronic condition reported by parents both at 7 and at 16 years of age was obtained from the Northern Finland Birth Cohort 1986 (NFBC 1986), which is a longitudinal 1-year birth cohort (n = 9432) from an unselected, regionally defined population. Internalizing and externalizing problems were measured at 8 years of age with Rutter Children's Behavioral Questionnaire by teachers and at 16 years of age with Youth Self-Report by adolescents. When studying the effects of history of chronic conditions on these problems at 16 years of age, childhood internalizing and externalizing problems and social relations were adjusted. A history of chronic condition predicted subsequent somatic complaints among all adolescents. Early-onset chronic conditions were related to subsequent externalizing (OR 1.35; 1.02-1.79) and attention problems (OR 1.33; 1.01-1.75) and later onset of chronic conditions with internalizing (OR 1.49; 1.22-1.82) and thought problems (OR 1.50; 1.18-1.92). The effect was specific for sex and the type of chronic condition.

CONCLUSION

Childhood chronic conditions predicted internalizing and externalizing problems in adolescence. To prevent poor mental health trajectories, children with chronic conditions during their growth to adolescence need early support and long-term monitoring.

WHAT IS KNOWN

• Childhood adversities increase the risk of mental disorders. • Internalizing and externalizing problems have been suggested for measuring childhood and adolescent psychopathologies.

WHAT IS NEW

• Having a chronic condition (CC) before the age of 7 or later but before the age of 16 had different outcomes in adolescence. The early onset predicted externalizing problems, whereas the late onset predicted internalizing problems and thought problems in adolescence. The risk of somatic complaints was increased regardless of CC onset time. These findings can reflect more restricted ability to mental processing in the younger children.

Assessing children's defense mechanisms with the Defense Mechanisms Rating Scales Q-sort for Children

Defense mechanisms are unconscious and automatic psychological processes that serve to protect the individual from painful emotions and thoughts. There is ample evidence from the adult psychotherapy and mental health literature suggesting the salience of defenses in the maintenance and amelioration of psychological distress. Although several tools for the assessment of children's defenses exist, most rely on projective and self-report tools, and none are based on the empirically derived hierarchy of defenses. This paper outlines the development of the defense mechanisms rating scale Q-sort for children (DMRS-Q-C), a 60-item, observer-rated tool for coding the use of defenses in child psychotherapy sessions. Modifications to the Defense Mechanisms Rating Scale Q-Sort for adults to create a developmentally relevant measure and the process by which expert child psychotherapists collaborated to develop the DMRS-Q-C are discussed. A clinical vignette describing the child's defensive functioning as assessed by the innovative DMRS-Q-C method is also reported. Finally, we provide an overview of forthcoming research evaluating the validity of the DMRS-Q-C.

Associations Between Defence-Style, Eating Disorder Symptoms, and Quality of Life in Community Sample of Women: A Longitudinal Exploratory Study

Background and Aim: Eating Disorders (EDs) impact an estimated 15% of the global population and are linked to maladaptive defence-styles (coping strategies) and poorer mental health outcomes. Defence-styles have been grouped into immature, neurotic, and mature behaviours. Studies have yet to examine all three defence-styles in ED symptomatic individuals over an extended period of time. The current study aimed to investigate using converse analysis the relationships between defence-style and ED outcomes over a 5-years period. Methods: Participants (n = 216, mean age 33 years) were recruited through the Women's Eating and Health Literacy study, with the current study examining a 5-years period of two waves (year-4 and year-9). The current study tested associations over time between eating pathology (EDE-Q), psychological distress (K10), mental and physical health related quality of life (M/PHRQoL, SF-12), and defence-style (DSQ-40). Results: Mature, immature and neurotic defence-styles did not significantly change over 5 years. Over the same period, only PHRQoL significantly predicted mature defence-styles having positive effect. Both MHRQoL and PHRQoL significantly predicted immature defence-styles having positive and negative effects, respectively. Psychological distress, PHRQoL and weight concern significantly predicted neurotic defence-styles having positive effects except for psychological distress. PHRQoL, MHRQoL, restraint and eating concern significantly predicted overall eating pathology having positive effects except for PHRQoL and MHRQoL. Conversely, among the defence-style variables, over 5 years, both immature and neurotic defence-styles significantly predicted psychological distress having positive effects, immature and mature defence-styles significantly predicted MHRQoL having negative and positive effects, respectively, while only immature defence-styles significantly predicted overall eating pathology having positive effect. Conclusions: The results of the current study suggest that immaturity and neuroticism but not maturity were the defence-style variables predicting psychological distress over a 5-years period while conversely psychological distress predicted only neurotic defence styles. The findings of the current study may suggest that without intervention, mature, immature and neurotic defence-styles may largely remain immutable to significant shifts over time. Limitations in the current study included limited demographic representation. The current study is anticipated to generate considerations into treatments that could strengthen defence-styles in individuals with increased eating pathology.

Defense Mechanisms, Gender, and Adaptiveness in Emerging Personality Disorders in Adolescent Outpatients

The present study focused on demographic and personality differences in the use of 30 defense mechanisms in adolescents with personality psychopathology and explored the hierarchical organization of personality traits based on the adaptiveness of defensive functioning. A total of 102 self-referred adolescent outpatients were interviewed and assessed on defense mechanisms and personality traits using the Defense Mechanisms Rating Scales and the Shedler-Westen Assessment Procedure 200 for Adolescents, respectively. Age and gender differences were found throughout the hierarchy. Pearson's correlations revealed a hierarchical organization of emerging personality disorders (PDs) in adolescence. More adaptive defenses were clearly associated with healthier personality style, whereas more pathological personality styles such as those with borderline traits were characterized by more rigid and maladaptive defenses. Dissociation was also associated with maladaptive personality types. Identifying the defenses associated with emerging personality disorders may inform the unconscious function of defense mechanisms in specific PDs. The systematic assessment of defense mechanisms might also help therapists to monitor changes during treatment.

Preliminary Reliability and Validity of the DMRS-SR-30, a Novel Self-Report Measure Based on the Defense Mechanisms Rating Scales

Defense mechanisms are psychological factors that influence emotional distress and quality of life. There are a number of measures assessing the construct of defense mechanisms, but only few available instruments reflect the gold-standard theoretical hierarchical organization of defenses. We report on the development of a novel 30 item self-report questionnaire, the DMRS-SR-30, based on the parent instrument, the Defense Mechanism Rating Scales (DMRS). This study tested preliminary reliability and validity of the Italian version of the DMRS-SR-30. We first extracted 30 items from the DMRS Q-sort version (DMRS-Q) and adapted them for a self-reported format. We then applied the DMRS quantitative scoring algorithms to provide proportional scores for the 28 individual defenses and summary scores for seven defense levels and overall defensive functioning (ODF) scores. A dynamic interview was used for assessing participant's defense mechanisms with the observer-rated DMRS and DMRS-Q. We examined internal consistency of the scales along with criterion, concurrent, convergent and discriminant validity among participants (N = 94) who completed the DMRS-SR-30, SCL-90, BDI, and IES-R. Results showed very good internal consistency for ODF (Cronbach's alpha = .890) and the high adaptive defense level, whereas some subscales with few items had lower values. Correlation analyses between DMRS-SR-30 and the two DMRS-based observer-rated measures showed very good criterion and concurrent validity for ODF and moderate to high for defense levels subscales. Correlations between the DMRS-SR-30 ODF and SCL-90 GSI, BDI and IES=R (r = -.456, r= -.540, r = -.402, respectively, all p <.001), indicated good convergent validity. Despite the well-known limitations of self-report methods of psychodynamic phenomena, self-report measures are highly practicable for assessing large samples. The DMRS-SR-30 is the first self-assessed measure describing the whole hierarchy of 28 defense mechanisms and providing scores for ODF, defensive categories, defense levels, and individual defenses. Preliminary examination of the Italian version of the DMRS-SR-30 showed promising results of internal consistency, criterion and concurrent validity, and convergent validity and of the measure. Further validation is needed to confirm these findings and explore other aspects of validity and reliability.

Defense Style of Children and Adolescents: Differences and Ability to Discriminate Among Clinical Categories

This study assessed the defense style of children referred to an outpatient clinic and examined what this style contributes to discriminating among various disorder categories, beyond internalizing and externalizing symptoms. A sample of 433 children and adolescents were grouped into four disorder categories: disruptive, depressive, anxiety, and attention deficit hyperactivity disorder. Their parents completed the Comprehensive Assessment of Defense Style (CADS: mature, self-oriented, and other-oriented) and the Child Behavior Checklist (CBCL: internalizing and externalizing symptoms). The disorder categories differed in the use of other-oriented defenses (e.g., acting-out, projection), whereas the CADS helped in properly discriminating most diagnostic categories beyond the CBCL. Information provided by the children themselves was missing, as was a subsample of nonclinical participants; these sources could strengthen the conclusions of the study. Assessing children's defense style together with their symptoms may result in better statistical discrimination among diagnostic categories.

The Role of Defense Mechanisms in Emerging Personality Disorders in Clinical Adolescents

Background: Defensive functioning is related to overall mental functioning and personality traits in adults but only few studies investigated the role of defenses in adolescence. The present study analyzed the use of defense mechanisms in clinical adolescents to test how defensive functioning is related to age, gender, and personality traits.Design: 102 self-referred outpatients were interviewed using the Clinical Diagnostic Interview (CDI). Defense mechanisms and personality profile were assessed using the Defense Mechanisms Rating Scale (DMRS) and the Shedler-Westen Assessment Procedure-200 for Adolescence (SWAP-200-A) respectively.Findings: Multivariate analysis of variance showed significant age and gender differences in clinical adolescents; while younger teenagers used more immature defenses, older adolescents scored significantly higher in high-neurotic and mature defenses. Girls showed higher use of minor image distortion and neurotic defenses, whereas boys recurred more frequently to obsessional level defenses. Neither age nor gender differences were found for narcissistic defense level. Significant correlations between personality disorders and specific defenses were found for all personalities with sufficient base rate, with the exception of paranoid, schizotypal, and schizoid personalities.Conclusions: In line with previous studies we confirmed the hypothesis of an ontogenetic line of development of defense mechanisms. In addition, the present study found that age and gender differences in adolescence are related to the use of specific defenses that contribute to the development of the personality and various psychological capacities. Several clinical implications are linked to the systematic investigation of defense mechanisms in youth, although further studies are required to confirm these findings.

Change in Children's Self Confidence and the Use of Defense Mechanisms

Change in the personality trait of self-confidence was studied in a group of children from the Berkeley Guidance Longitudinal study. Self-confidence was assessed at age 6 (n = 99) and again at age 10 (n = 97). Results indicated that a change in level of self-confidence was related to the use of defense mechanisms, as assessed from Thematic Apperception Test stories. A decrease in self-confidence was positively related to the use of the immature defense of denial and negatively related to the use of the relatively mature defense of identification. In contrast, an increase in self-confidence was unrelated to the use of defense mechanisms.

The protective role of maternal posttraumatic growth and cognitive trauma processing among Palestinian mothers and infants

War survivors use multiple cognitive and emotional processes to protect their mental health from the negative impacts of trauma. Because mothers and infants may be especially vulnerable to trauma in conditions of war, it is urgent to determine which cognitive and emotional processes are effective for preventing negative trauma impacts." This study examined whether mothers' high posttraumatic growth (PTG) and positive posttraumatic cognitions (PTC) protected (a) their own mental health and (b) their infants' stress regulation and sensorimotor and language development from the effects of war trauma. The participants were 511 Palestinian mothers and their infants living in the Gaza strip. The mothers were interviewed in their second trimester of pregnancy (T1) as well as when the infant was four months (T2) and twelve months (T3). Mothers reported posttraumatic growth (PTG; Tedeschi & Calhoun, 1996) at T1 and posttraumatic cognitions (PTCI; Foa et al., 1999) at T2. They also reported their exposure to traumatic war events both at T1 and T3 and described their mental health conditions (e.g., PTSD and/or depressive and dissociation symptoms) at T3. The Infant Behaviour Questionnaire (IBQ) was used to measure infants' stress regulation at T2 and sensorimotor and language development at T3. The results, based on regression analyses with interaction terms between trauma and PTG, showed that high levels of traumatic war events were not associated with high levels of PTSD, depressive, or dissociation symptoms among mothers showing high levels of PTG. This suggests that PTG may protect maternal mental health from the effects of trauma. In turn, positive maternal PTCs appeared to protect the infants' stress regulation from the effects of war trauma. The study concludes by discussing ways to develop and implement preventive interventions for mother-infant dyads in war conditions.

Adolescent Defense Style as Correlate of Problem Behavior

Abstract. Objective: Adolescent problem behaviors are often the visible results of intrapsychic distress. Defensive reactions are the unconscious means of managing intrapsychic distress. This cross-sectional study examines the strength of defensive style as measured by self-report on the Response Evaluation Measure (REM-71) relative to age, sex, and SES, as a correlate of internalizing and externalizing problem behaviors, as assessed by the Youth Self Report (YSR). Methods: A sample of 1,487 students from two suburban high schools completed self-report measures of defense style, self-esteem, and internalizing and externalizing problem behaviors. Demographic variables (age, sex, and SES) were included as covariates. Results: Mature and immature defense style correlated as expected with problem behaviors. Demographic variables contributed minimally to the variance in the outcome variable. Conclusions: Defense style, as assessed by the REM-71, is a significant correlate of clinically elevated internalizing and externalizing problem behaviors in youth as in adults. This study adds to the convergent validity of the REM-71.

Preventing children's posttraumatic stress after disaster with teacher-based intervention: a controlled study

OBJECTIVE

The psychological outcomes that the exposure to mass trauma has on children have been amply documented in the past decades. The objective of this study is to describe the effects of a universal, teacher-based preventive intervention implemented with Israeli students before the rocket attacks that occurred during Operation Cast Lead, compared with a nonintervention but exposed control group.

METHOD

The study sample consisted of 1,488 students studying in fourth and fifth grades in a city in southern Israel who were exposed to continuous rocket attacks during Operation Cast Lead. The intervention group included about half (53.5%) of the children who studied in six schools where the teacher-led intervention was implemented 3 months before the traumatic exposure. The control group (46.5% of the sample) included six schools matched by exposure in which the preventive intervention was not implemented. Children filled out the UCLA-PTSD Reaction Index and the Stress/Mood Scale 3 months after the end of the rocket attacks.

RESULTS

The intervention group displayed significantly lower symptoms of posttrauma and stress/mood than the control group (p < .001). Control children had 57% more detected cases of postraumatic stress disorder (PTSD) than participant children. This difference was significantly more pronounced among boys (10.2% versus 4.4%) and less among girls (12.5% versus 10.1%).

CONCLUSIONS

The teacher-based, resilience-focused intervention is a universal, cost-effective approach to enhance the preparedness of communities of children to mass trauma and to prevent the development of PTSD after exposure.

Defense mechanisms development in typical children

The defense mechanisms (DMs) of 103 nonreferred children ages 47 to 102 months were assessed through dollhouse play. The authors measured the children's temperament (Temperament Assessment Battery for Children-Teacher Form [TABC]) and verbal capacities (Wechsler Preschool and Primary Scale of Intelligence or Wechsler Intelligence Scale for Children). Four main findings were derived: (1) DM use decreased with age with different developmental trajectories; (2) regression, displacement, and reaction formation were more frequent in girls and denial more frequent in boys; (3) the number of DMs used was negatively associated with the TABC Adaptability score and positively with the TABC Approach/Withdrawal score; and (4) children who used rationalization and did not use identification and suppression scored better on verbal capacities.

Assessing defense structure in school-age children using the Response Evaluation Measure-71-Youth version (REM-Y-71)

This study used the Response Evaluation Measure-Youth (REM-Y-71), a self-report measure of 21 defense reactions, among school-age children. Participants were elementary and middle school students (n = 290; grades 3-8; age range: 8-15; mean = 11.73). Factor analysis revealed a 2-factor defense structure consistent with structure among high school and adult samples. The composite REM-Y defense scores for each factor were significant predictors of social desirability, using the Children's Defensiveness Scale (CDS); anxiety, using the State-Trait Anxiety Inventory for Children (STAIC); and psychosocial functioning. This study represents the first cross-sectional empirical analysis of overall defense structure and use among children and early adolescents.

Defense mechanisms in adolescent conduct disorder and adjustment reaction

The use of defense mechanisms by male and female adolescents with a diagnosis of conduct disorder was compared with the defense use of adolescents with a diagnosis of adjustment reaction. Because conduct disorder has been shown to be associated with a developmental lag in several areas of psychological functioning, we expected that these adolescents would show immaturity in the use of defenses. This expectation was confirmed. As compared with adjustment reaction, conduct disordered youths were more likely to use the immature defense of denial and less likely to use the mature defense of identification.

Defense styles, personality traits, and psychopathological symptoms in nonclinical adolescents

The purpose of the present study was to examine relationships between defense styles, personality traits, and psychopathological symptoms in nonclinical youths. A large sample of adolescents (n = 437) completed the Defense Style Questionnaire for Adolescents, the Junior version of the Eysenck Personality Questionnaire, and a scale measuring symptoms of DSM-defined disorders. Results showed that there were clear relationships between personality traits (neuroticism and psychoticism) and defense styles (neurotic and immature defense) on the one hand and psychopathological symptoms on the other hand. Most importantly, regression analyses indicated that personality traits and defense styles both accounted for unique proportions of the variance in psychopathological symptoms.

Defense mechanisms and psychological adjustment in childhood

The association between maturity of defense use and psychological functioning was assessed in a group of 95 elementary school children. Defense mechanisms were measured using a valid and reliable storytelling task, and psychological adjustment was assessed through a combination of parent and self-report questionnaires. Correlational analyses indicated that children who relied on the developmentally immature defense of denial reported higher levels of self-rated social anxiety and depression and received higher ratings of parent-reported internalizing and externalizing behavior problems. However, children who made use of the developmentally mature defense of identification exhibited higher scores on perceived competence in social, academic, conduct, athletic, and global domains. Significantly, there was no relationship between children's use of denial and their level of perceived competence or between children's use of identification and their degree of maladjustment.

Dissociative symptoms in posttraumatic stress disorder: diagnosis and treatment

This article explores the complex relationship between dissociation and psychiatric trauma. Dissociation is described as a defense reaction, a risk factor for the development of posttraumatic stress disorder, and as a set of syndromal disturbances. The authors discuss various models proposed for the relationship between these. They outline developmental considerations in diagnosis and treatment and end by discussing further needed research.

Validation of the Comprehensive Assessment of Defense Style (CADS): mothers' and children's responses to the stresses of missile attacks

This study furthers the validation of the Comprehensive Assessment of Defense Style (CADS) as a measure of children's defensive behavior. Participants were 81 mothers who assessed the defense style (CADS) of their 8- to 10-year-old children, as well as their own defense style and level of object relations. Five years earlier, the mothers had rated their children's symptom level and personality after the missile attacks during the Gulf War. The original factor structure of the CADS was replicated for the most part. Self-oriented and other-oriented defenses were related to the children's early personality and symptomatic reaction, as well as to their mother's defense style and level of object relations. The CADS factors correlated with the defenses of the Defense Mechanisms Manual. The results provide further validation of the CADS and suggest possible areas of implementation, such as longitudinal examination of defenses, psychopathology screening, and therapeutic improvement.